- Payers rely on process and outcome quality measures to communicate healthcare performance to new and current beneficiaries.
Quality measurements such as HEDIS, CMS Star Ratings, and standardized core quality measures (CQMs) are some of the tools used to develop objective comparisons between payers. Quality measurement sets also help develop high-value healthcare because they can provide a snapshot of how well clinical services are being performed and if services are cost-effective for beneficiaries.
Process and outcomes measures reveal if beneficiaries are receiving recommended preventive care and treatments, and if services rendered led to positive health outcomes.
Leveraging both process and outcome measures can help payers understand if their current strategies are effective and devise new strategies to increase care quality that is cost-efficient.
What are process measures?
“Process measures indicate what a provider does to improve or maintain health and typically reflect general healthcare recommendations,” according to AHRQ.
Process measures can be used to record how many times a service was performed for a targeted population, such as the number of diabetics that had their blood pressure tested.
These measures can also help payers and providers identify gaps in care by giving some insight into which patients may not have had the service performed, and why the service was skipped.
The HEDIS dataset contains process measures that record if screenings and health assessments took place within vulnerable populations. HEDIS process measures help identify the number spirometry tests administered to diagnose COPD, the number of breast cancer screenings performed, and the amount of immunizations given to adolescent beneficiaries.
CQMs take a more specific approach to process measures by combining several processes to determine whether or not a bundle of healthcare services was performed. One CQM measure takes into account screening and cessation services to collectively record multiple preventive services for individual tobacco users.
How do outcome measures differ from process measures?
Outcome measures indicate the results of a process, such as if a patient’s condition improved or worsened after receiving a specific service.
Outcome measures include quality indicators such as medication adherence, blood pressure control in COPD patients, and surgery-induced mortality rates. While outcome measures can be influenced by uncontrollable non-medical factors, these measures still have the potential to reveal detailed insights about beneficiary healthcare quality.
The outcome measures in the HEDIS dataset record treatment persistence over time, health condition monitoring, and follow-up interventions.
HEDIS outcome measures include metrics such as persistence of cardiovascular treatment after a heart attack, medication adherence to antipsychotic therapies for schizophrenia patients, and follow up primary care visits after a patient with multiple chronic conditions experiences a hospital admission through the ED.
CQM outcome measures record outcomes among beneficiary populations including if beneficiaries experienced adverse effects during treatment and the success of preventive care services.
For example, one CQM measures “the percentage of patients 5-64 years of age during a measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period.”
How do process and outcomes quality measures reflect payer success in developing low-cost, high quality care?
Both process and outcome measures indicate the quality of health plans and can help determine if payer strategies for providing cost-effective quality healthcare are succeeding.
Payers looking to improve their population health management capabilities can determine if strategies such as adjusting the pricing of chronic disease treatments led to more processes and improved patient outcomes. Process and quality measures also reflect if payers are effectively identifying beneficiaries at risk for chronic diseases and other high-cost conditions.
Process measures can determine the volume at which cost-effective preventive services are performed, while outcome measures give a payer insight into the relationship between preventive services and healthier outcomes.
Both process and outcome measurements present an opportunity for payers to further develop population health insights and improve care quality for their beneficiaries.